<style>
.theme-white .tpl-table-black tbody > tr > td{ line-height:30px; padding:10px;}
.theme-white .tpl-table-black tbody > tr > td.valign{ vertical-align:middle; text-align:center;}
</style>
<div class="row">
    <div class="am-u-sm-12 am-u-md-12 am-u-lg-12">
        <div class="widget am-cf">
        	<div class="widget-head am-cf">
                <div class="widget-title  am-fl"><a href='javascript:;' onclick="history.go(-1);return false;" class="am-btn am-btn-default am-round" ><span class="am-icon-mail-reply"></span> 返回</a></div>
                <div class="widget-function am-fr custom-tab">{{template "outpatient/tabmenu.html" .}}</div>
            </div>
        	<form action='{{urlfor "ArchivesController.SaveInterrogations"}}' id="formDoSubmit" method="post" class="am-form tpl-form-line-form my-form" style="padding-top:0;">
            <input type="hidden" name="Id" value="0" />
            <input type="hidden" name="Archives" value="{{.m.Id}}" />
            <div class="widget-body am-fr">
            	<div class="row am-cf">
                	{{template "outpatient/userinfo.html" .}}
               	        <div  id="print_table">
                        <table class="am-table am-table-compact am-table-bordered tpl-table-black am-text-nowrap tables">
                        	<tbody>
                              <tr>
                                <td colspan="10"><div class="am-text-lg am-text-center">问诊（档案编号：<span id="Number">{{.number}}</span><span id="created_at"></span>）</div></td>
                              </tr>
                              <tr>
                                <td>首诊日期</td>
                                <td><input type="text" name="StartDate" data-am-datepicker id="StartDate" value="{{.nowDate}}" readonly="readonly"/></td>
                                <td>首诊医生</td>
                                <td>
                                	<select class="am-input-sm" name="StartDoctor" id="StartDoctor">
                                    {{range $k, $v := .c.doctor}}
                                        <option value="{{$v.OptionName}}">{{$v.OptionName}}</option>
                                    {{end}}
                                   </select>
                                </td>
                                <td>接诊医生</td>
                                <td><input name="MeetDoctor" type="text" id="MeetDoctor" size="20" value="{{.backenduser.RealName}}"/></td>
                                <td>验配师</td>
                                <td>
                                <select class="am-input-sm" name="Optometrist" id="Optometrist" >
                                {{range $k, $v := .c.optometrist}}
                                    <option value="{{$v.OptionName}}">{{$v.OptionName}}</option>
                                {{end}}
                            	</select>
                                </td>
                                <td>医院</td>
                                <td><input name="Hospital" type="text" id="Hospital" size="60" value="{{.department.Name}}"/></td>
                              </tr>
                              <tr>
                                <td rowspan="11" class="valign">询问</td>
                                <td rowspan="2" class="valign">患者主诉</td>
                                <td colspan="8">
                                	<textarea name="MainSuit" id="MainSuit" rows="5"></textarea>
                                </td>
                              </tr>
                              <tr>
                                <td>视力下降开始时间</td>
                                <td colspan="7"><input type="text" style="width:180px;" name="VisionDeclineDate" data-am-datepicker="data-am-datepicker" id="VisionDeclineDate" readonly="readonly"/></td>
                              </tr>
                              <tr>
                                <td rowspan="5" class="valign">视觉病史</td>
                                <td>此前结论</td>
                                <td colspan="7">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="BeforeConclusion[]" value="1"> 近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeConclusion[]" value="2"> 远视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeConclusion[]" value="3"> 散光</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeConclusion[]" value="4"> 弱视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeConclusion[]" value="5"> 其它</label>
                                </td>
                              </tr>
                              <tr>
                                <td>此前治疗方案</td>
                                <td colspan="7">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="1"> 框加眼镜</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="2"> 遮盖</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="3"> 塑性镜</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="4"> RGP</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="5"> 中医</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="6"> 药物</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="7"> 视觉训练</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="8"> 斜视手术</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="BeforeTreatment[]" value="9"> 其它</label>
                                </td>
                              </tr>
                              <tr>
                                <td>此前治疗效果</td>
                                <td colspan="3" class="am-text-center">右眼（OD）</td>
                                <td colspan="4" class="am-text-center">右眼（OS）</td>
                              </tr>
                              <tr>
                                <td class="am-text-center">视力：从</td>
                                <td><input name="VisionChange1" type="text" id="VisionChange1" size="20" /></td>
                                <td class="am-text-center">变化到</td>
                                <td><input type="text" name="VisionChange2" id="VisionChange2" size="20"/></td>
                                <td class="am-text-center">从</td>
                                <td><input type="text" name="VisionChange3" id="VisionChange3" size="20"/></td>
                                <td class="am-text-center">变化到</td>
                                <td><input type="text" name="VisionChange4" id="VisionChange4" size="20"/></td>
                              </tr>
                              <tr>
                                <td class="am-text-center">屈光度：从</td>
                                <td><input type="text" name="RefractionChange1" id="RefractionChange1" size="20"/></td>
                                <td class="am-text-center">变化到</td>
                                <td><input type="text" name="RefractionChange2" id="RefractionChange2" size="20"/></td>
                                <td class="am-text-center">从</td>
                                <td><input type="text" name="RefractionChange3" id="RefractionChange3" size="20"/></td>
                                <td class="am-text-center">变化到</td>
                                <td><input type="text" name="RefractionChange4" id="RefractionChange4" size="20"/></td>
                              </tr>
                              <tr>
                                <td class="valign">用眼时间</td>
                                <td>每天近距用眼时间</td>
                                <td>
                                	<select style="width:120px;" name="Nearuseeye" id="Nearuseeye">
                                      <option value=""></option>
                                      <option value="1">1小时</option>
                                      <option value="2">2小时</option>
                                      <option value="3">3小时</option>
                                      <option value="4">4小时</option>
                                      <option value="5">5小时</option>
                                      <option value="6">6小时</option>
                                      <option value="7">7小时</option>
                                      <option value="8">8小时</option>
                                      <option value="10">9小时以上</option>
                                    </select>
                                </td>
                                <td>每天户外活动时间</td>
                                <td>
                                	<select style="width:120px;" name="OutdoorActivities" id="OutdoorActivities">
                                     <option value=""></option>
                                      <option value="1">1小时</option>
                                      <option value="2">2小时</option>
                                      <option value="3">3小时</option>
                                      <option value="4">4小时</option>
                                      <option value="5">5小时</option>
                                      <option value="6">6小时</option>
                                      <option value="7">7小时</option>
                                      <option value="8">8小时</option>
                                      <option value="10">9小时以上</option>
                                    </select>
                                </td>
                                <td>每天睡眠时间</td>
                                <td>
                                	<select style="width:120px;" name="SleepTime" id="SleepTime">
                                      <option value=""></option>
                                      <option value="1">1小时</option>
                                      <option value="2">2小时</option>
                                      <option value="3">3小时</option>
                                      <option value="4">4小时</option>
                                      <option value="5">5小时</option>
                                      <option value="6">6小时</option>
                                      <option value="7">7小时</option>
                                      <option value="8">8小时</option>
                                      <option value="10">9小时以上</option>
                                    </select>
                                </td>
                                <td>&nbsp;</td>
                                <td>&nbsp;</td>
                              </tr>
                              <tr>
                                <td class="valign">既往史</td>
                                <td colspan="8">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="PastHistory[]" value="1"> 过敏史</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="PastHistory[]" value="2"> 早产</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="PastHistory[]" value="3"> 母乳喂养</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="PastHistory[]" value="4"> 体质较差</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="PastHistory[]" value="5"> 其它眼病</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="PastHistory[]" value="6"> 其它全身疾病</label>
                                </td>
                              </tr>
                              <tr>
                                <td class="valign">遗传因素</td>
                                <td colspan="8">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="Inheritance[]" value="1"> 父母无近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Inheritance[]" value="2"> 父母均近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Inheritance[]" value="3"> 父亲近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Inheritance[]" value="4"> 母亲近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Inheritance[]" value="5"> 祖父母近视</label>
                                </td>
                              </tr>
                              <tr>
                                <td class="valign">环境行为因素</td>
                                <td colspan="8">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="1"> 弹琴</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="2"> 拉小提琴</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="3"> 绘画</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="4"> 书法</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="5"> 喜欢手工</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="6"> 喜欢小玩具</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="7"> 看书时间长</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="8"> 看电视</label>
                                    <br />
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="9"> 玩手机、电脑、平板</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="10"> 写字姿势不正确</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="11"> 提笔姿势不正确</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Environment[]" value="12"> 其它</label>
                                </td>
                              </tr>
                              <tr>
                                <td rowspan="4" class="valign">诊断</td>
                                <td class="valign">屈光</td>
                                <td colspan="4">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="RefractionOd[]" value="1"> 屈光正常</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOd[]" value="2"> 近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOd[]" value="3"> 高度近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOd[]" value="4"> 远视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOd[]" value="5"> 高度远视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOd[]" value="6"> 散光</label>
                                </td>
                                <td colspan="4">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="RefractionOs[]" value="1"> 屈光正常</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOs[]" value="2"> 近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOs[]" value="3"> 高度近视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOs[]" value="4"> 远视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOs[]" value="5"> 高度远视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="RefractionOs[]" value="6"> 散光</label>
                                </td>
                              </tr>
                              <tr>
                                <td class="valign">弱视</td>
                                <td colspan="4">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="AmblyopiaOd[]" value="1"> 斜视性弱视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="AmblyopiaOd[]" value="2"> 屈光不正性</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="AmblyopiaOd[]" value="3"> 屈光参差性</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="AmblyopiaOd[]" value="4"> 形觉剥夺性</label>
                                </td>
                                <td colspan="4">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="AmblyopiaOs[]" value="1"> 斜视性弱视</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="AmblyopiaOs[]" value="2"> 屈光不正性</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="AmblyopiaOs[]" value="3"> 屈光参差性</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="AmblyopiaOs[]" value="4"> 形觉剥夺性</label>
                                </td>
                              </tr>
                              <tr>
                                <td>其它结论</td>
                                <td colspan="4"><textarea name="OtherConclusionOd" id="OtherConclusionOd" rows="4"></textarea></td>
                                <td colspan="4"><textarea name="OtherConclusionOs" id="OtherConclusionOs" rows="4"></textarea></td>
                              </tr>
                              <tr>
                                <td>方案建议</td>
                                <td colspan="8">
                                	<label class="am-checkbox-inline"><input type="checkbox" name="Proposal[]" value="1"> 角膜塑形镜</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Proposal[]" value="2"> RGP</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Proposal[]" value="3"> 近视防控软镜</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Proposal[]" value="4"> 训练</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Proposal[]" value="5"> 中医</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Proposal[]" value="6"> 药物</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Proposal[]" value="7"> 框架眼镜</label>
                                    <label class="am-checkbox-inline"><input type="checkbox" name="Proposal[]" value="8"> 阿托品</label>
                                </td>
                              </tr>
                              
                            </tbody>
                    </table>
                        </div>
                    <div class="row" style="text-align:center;">
                      <button class="am-btn am-btn-secondary" type="submit">保存问诊</button>
                  </div>
                    
			  </div>
            </div>
          </form>  
        </div>
    </div>
</div>